Implantable cardiac device providing intrinsic conduction search with premature atrial contraction protection and method

ABSTRACT

The extended AV interval of an auto intrinsic conduction search of an implantable cardiac stimulation device has premature atrial contraction protection. A timer times a base AV interval and the extended AV interval. If the heart is paced with the extended AV interval and a premature atrial contraction is detected, the extended AV interval is maintained. Once a predetermined number of consecutive premature atrial contractions are detected, the extended AV interval is reset to the base AV interval.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of copending U.S. patent applicationSer. No. 11/219,063, filed Sep. 1, 2005, titled “Implantable CardiacDevice Providing Intrinsic Conduction Search With Premature AtrialContraction Protection And Method.”

FIELD OF THE INVENTION

The present invention generally relates to an implantable cardiacdevice. The present invention more particularly relates to animplantable pacemaker capable of providing intrinsic conductionsearching while also maintaining intrinsic conduction with respect topremature atrial contractions in combination with the intrinsic searchalgorithm.

BACKGROUND OF THE INVENTION

Implantable cardiac devices are well known in the art. They may take theform of implantable defibrillators or cardioverters which treataccelerated rhythms of the heart such as fibrillation. They may alsotake the form of implantable pacemakers which maintain the heart rateabove a prescribed limit, such as, for example, to treat a bradycardia.Implantable cardiac devices are also known which incorporate both apacemaker and a defibrillator.

A pacemaker is comprised of two major components. One component is apulse generator which generates the pacing stimulation pulses andincludes the electronic circuitry and the power cell or battery. Theother component is the lead, or leads, which electrically couple thepacemaker to the heart.

Pacemakers deliver pacing pulses to the heart to cause the stimulatedheart chamber to contract when the patient's own intrinsic rhythm fails.To this end, pacemakers include sensing circuits that sense cardiacactivity for the detection of intrinsic cardiac events such as intrinsicatrial events (P waves) and intrinsic ventricular events (R waves). Bymonitoring such P waves and/or R waves, the pacemaker circuits are ableto determine the intrinsic rhythm of the heart and provide stimulationpacing pulses that force atrial and/or ventricular depolarizations atappropriate times in the cardiac cycle when required to help stabilizethe electrical rhythm of the heart.

Pacemakers are described as single-chamber or dual-chamber systems. Asingle-chamber system stimulates and senses the same chamber of theheart (atrium or ventricle). A dual-chamber system stimulates and/orsenses in both chambers of the heart (atrium and ventricle).Dual-chamber systems may typically be programmed to operate in either adual-chamber mode or a single-chamber mode.

A popular mode of operation for dual-chamber pacemakers is the DDD mode.Specifically, DDD systems provide atrial pacing during atrialbradycardia, ventricle pacing in the setting of overt AV block or evencompromised AV nodal conduction such as first degree AV block, andatrial and ventricular pacing during combined atrial and ventricularbradycardia or heart block also known as AV block. In addition, DDDRsystems monitor patient activity levels for controlling pacing rate tomore closely approximate the normal response of the heart to exercise,or other physiological activity demanding a faster heart rate.

Recent studies have indicated, however, that ventricular pacing in thesetting of intact AV nodal conduction may have an adverse impactcompared to permitting intrinsic ventricular contractions. Hence, pacingtherapies have been advanced which encourage intrinsic ventricularactivity while still providing back-up ventricular support should AVblock develop. One such system employs an algorithm labeled autointrinsic conduction search (AICS) wherein the pacemaker utilizes two AVintervals. The first interval is a programmable base AV interval tosupport ventricular demand pacing. It may be, for example, on the orderof two hundred (200) milliseconds. The second AV interval is an extendedAV interval which may be thought of as comprising the base AV intervalwith an AV interval extension added to its end. The AV intervalextension may be on the order of one hundred (100) milliseconds, forexample. Hence, in this example, the extended AV interval would be onthe order of three hundred (300) milliseconds.

The AICS may be implemented as follows. Over a preset interval, forexample five minutes, the device paces in a demand mode with the base AVinterval. At the end of the preset or programmable time period, thealgorithm extends the AV delay searching for intact AV nodal conduction.If a native QRS complex or “R wave” is detected during that extended AVdelay, the extension remains in effect and the system functions as if itwere a single chamber atrial pacemaker. The device does not reset to theshorter AV interval unless overt AV block occurs such that there is onecycle of AV pacing at the extended AV delay or the atrial rate exceeds aset upper atrial rate limit at which time the AV interval extension iscanceled with the system returning to the programmed base AV delay.Following this, even if the rate slows below this set upper atrial ratelimit, the programmed base AV delay remains in effect until the time-outoccurs and a search for intrinsic conduction is again performedautomatically by the algorithm. The upper atrial rate limit may beeither preset on the order of ninety (90) beats per minute (bpm), forexample or programmable.

Unfortunately, some patients with conduction delays at higher atrialrates run the risk of canceling the AICS feature if they have frequentpremature atrial complex (PACs). A premature atrial complex is an atrialdepolarization occurring early with respect to the basic sinus cycle. Itis not unusual for a PAC to result in an effective atrial rate greaterthan the upper atrial rate limit for the atrial cycle in which itoccurs. Hence, such an occurrence can run the risk of resetting the AICSextended AV interval to the base AV interval and reinitiate the fiveminute period of demand pacing at the shorter, base AV interval before asearch is performed. This is indeed unfortunate because, PACs aregenerally isolated events although occasionally they can occur in shortsalvos. It would, of course, be desirable for patients with intact AVconduction who experience PACs to benefit from intrinsic ventricularactivity and features such as AICS and not have this algorithmeffectively canceled by transient non-sustained events.

SUMMARY

What is described herein is an implantable cardiac stimulation devicecomprising a pulse generator that provides pacing pulses on demand to aheart chamber upon time-out of an inhibit interval, and a timer thattimes a base inhibit interval and an extended inhibit interval. Thedevice further comprises an intrinsic conduction control circuit thatcauses the timer to time the extended inhibit interval, a rate detectorthat detects a cardiac rate and causes the timer to time the baseinhibit interval upon detecting a cardiac rate above a given rate, and apremature contraction detector that detects premature contractions ofthe heart and that overrides the rate detector from causing the timer totime the base inhibit interval upon detection of a prematurecontraction.

The premature contraction detector overrides the rate detector for apredetermined number of consecutive cardiac cycles in which thepremature contraction detector detects a premature contraction. Thepulse generator is preferably a dual chamber pulse generator and theinhibit interval may be an AV interval.

The rate detector may be an atrial rate detector. The prematurecontraction detector preferably detects premature atrial contractions.The atrial rate detector may include a timer that times atrial basedintervals of consecutive cardiac cycles. The atrial based intervals maybe intervals from a ventricular activation to a succeeding atrialactivation. The atrial based intervals may alternatively be intervalsbetween an atrial activation of one cardiac cycle and an atrialactivation of a next succeeding cardiac cycle. The atrial rate intervalmay also be based on the ventricular rate from one ventricular event tothe next ventricular event as long as each ventricular event is precededby an atrial event at an appropriate AV delay.

The rate detector may cause the timer to time the base inhibit intervalupon detecting a cardiac rate above the given rate and time-out of theextended inhibit interval.

In another embodiment, an implantable cardiac stimulation devicecomprises a pulse generator that provides pacing pulses on demand to aventricle of a heart upon time-out of an AV interval, a timer that timesa base AV interval and an extended AV interval, and an intrinsicconduction control circuit that causes the timer to time the extended AVinterval when set and to time the base interval when reset. The devicefurther comprises an atrial rate detector that detects an atrial rateabove a given rate, a premature atrial contraction detector that detectspremature atrial contractions of the heart, and a reset circuit thatresets the intrinsic conduction control circuit responsive to the atrialrate detector detecting an atrial rate above the given rate in theabsence of a detected premature atrial contraction and that maintainsthe intrinsic conduction control circuit in a set condition when thepremature atrial contraction detector detects a premature atrialcontraction of the heart notwithstanding a detected atrial rate abovethe given rate. The reset circuit resets the intrinsic conductioncontrol circuit in response to a predetermined number of consecutivecardiac cycles in which the premature atrial contraction detectordetects a premature atrial contraction.

The atrial rate detector may include a timer that times atrial basedintervals of consecutive cardiac cycles. The premature atrialcontraction detector may include a subtractor that subtracts a currentatrial based interval from an immediately preceding atrial basedinterval to provide a difference, and a comparator that compares thedifference to a predetermined standard to detect a premature atrialcontraction.

The reset circuit may reset the intrinsic conduction control circuitwhenever there is a time-out of the extended AV interval. The resetcircuit may cause the timer to time the base AV interval for a cardiaccycle in which a premature atrial contraction is detected whilemaintaining the set condition.

In yet another embodiment, for use in an implantable cardiac stimulationdevice comprises providing pacing pulses on demand to a heart chamberupon time-out of an inhibit interval, providing a timer that times abase inhibit interval and an extended inhibit interval, and causing thetimer to time the extended inhibit interval. The method furthercomprises detecting a cardiac rate above a given rate, causing the timerto time the base inhibit interval upon detecting a cardiac rate abovethe given rate, detecting premature contractions of the heart, andcausing the timer to time the extended inhibit interval upon detectionof a premature contraction notwithstanding detection of a cardiac rateabove the given rate.

The step of causing the timer to time the base inhibit interval may beperformed upon detecting a cardiac rate above the given rate andtime-out of the extended inhibit interval. The timing of the extendedinhibit interval may be performed for each one of a plurality of cardiaccycles in which a premature contraction is detected.

BRIEF DESCRIPTION OF THE DRAWINGS

Further features and advantages of the present invention may be morereadily understood by reference to the following description taken inconjunction with the accompanying drawings, in which:

FIG. 1 is a simplified diagram illustrating an implantable stimulationdevice according to an embodiment of the present invention in electricalcommunication with a patient's heart;

FIG. 2 is a functional block diagram of the implantable stimulationdevice of FIG. 1 according to an embodiment of the present invention;and

FIG. 3 is a flow chart describing an overview of the operation of oneembodiment of the present invention.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

The following description is of the best mode presently contemplated forpracticing the invention. This description is not to be taken in alimiting sense but is made merely for the purpose of describing thegeneral principles of the invention. The scope of the invention shouldbe ascertained with reference to the issued claims. In the descriptionof the invention that follows, like numerals or reference designatorswill be used to refer to like parts or elements throughout.

As shown in FIG. 1, there is a stimulation device 10 in electricalcommunication with a patient's heart 12 by way of three leads, 20, 24and 30, suitable for delivering multi-chamber stimulation and shocktherapy. To sense atrial cardiac signals and to provide right atrialchamber stimulation therapy, the stimulation device 10 is coupled to animplantable right atrial lead 20 having at least an atrial tip electrode22, which typically is implanted in the patient's right atrialappendage.

To sense left atrial and ventricular cardiac signals and to provide leftchamber pacing therapy, the stimulation device 10 is coupled to a“coronary sinus” lead 24 designed for placement in the “coronary sinusregion” via the coronary sinus ostium for positioning a distal electrodeadjacent to the left ventricle and/or additional electrode(s) adjacentto the left atrium. As used herein, the phrase “coronary sinus region”refers to the vasculature of the left ventricle, including any portionof the coronary sinus, great cardiac vein, left marginal vein, leftposterior ventricular vein, middle cardiac vein, and/or small cardiacvein or any other cardiac vein accessible by the coronary sinus. Thecoronary sinus lead 24 is designed to receive atrial and ventricularcardiac signals and to deliver left ventricular pacing therapy using atleast a left ventricular tip electrode 26, left atrial pacing therapyusing at least a left atrial ring electrode 27, and shocking therapyusing at least a left atrial coil electrode 28.

The stimulation device 10 is also shown in electrical communication withthe patient's heart 12 by way of an implantable right ventricular lead30 having, in this embodiment, a right ventricular tip electrode 32, aright ventricular ring electrode 34, a right ventricular (RV) coilelectrode 36, and an SVC coil electrode 38. Typically, the rightventricular lead 30 is transvenously inserted into the heart 12 so as toplace the right ventricular tip electrode 32 in the right ventricularapex so that the RV coil electrode will be positioned in the rightventricle and the SVC coil electrode 38 will be positioned in thesuperior vena cava. Accordingly, the right ventricular lead 30 iscapable of receiving cardiac signals, and delivering stimulation in theform of pacing and shock therapy to the right ventricle.

As illustrated in FIG. 2, a simplified block diagram is shown of themulti-chamber implantable stimulation device 10, which is capable oftreating both fast and slow arrhythmias with stimulation therapy,including cardioversion, defibrillation, and pacing stimulation. While aparticular multi-chamber device is shown, this is for illustrationpurposes only, and one of skill in the art could readily duplicate,eliminate or disable the appropriate circuitry in any desiredcombination to provide a device capable of treating the appropriatechamber(s) with cardioversion, defibrillation and pacing stimulation.

The housing 40 for the stimulation device 10, shown schematically inFIG. 2, is often referred to as the “can”, “case” or “case electrode”and may be programmably selected to act as the return electrode for all“unipolar” modes. The housing 40 may further be used as a returnelectrode alone or in combination with one or more of the coilelectrodes, 28, 36 and 38, for shocking purposes. The housing 40 furtherincludes a connector (not shown) having a plurality of terminals, 42,44, 46, 48, 52, 54, 56, and 58 (shown schematically and, forconvenience, the names of the electrodes to which they are connected areshown next to the terminals). As such, to achieve right atrial sensingand pacing, the connector includes at least a right atrial tip terminal(A_(R) TIP) 42 adapted for connection to the atrial tip electrode 22.

To achieve left chamber sensing, pacing and shocking, the connectorincludes at least a left ventricular tip terminal (V_(L) TIP) 44, a leftatrial ring terminal (A_(L) RING) 46, and a left atrial shockingterminal (A_(L) COIL) 48, which are adapted for connection to the leftventricular ring electrode 26, the left atrial tip electrode 27, and theleft atrial coil electrode 28, respectively.

To support right chamber sensing, pacing and shocking, the connectorfurther includes a right ventricular tip terminal (V_(R) TIP) 52, aright ventricular ring terminal (V_(R) RING) 54, a right ventricularshocking terminal (R_(V) COIL) 56, and an SVC shocking terminal (SVCCOIL) 58, which are adapted for connection to the right ventricular tipelectrode 32, right ventricular ring electrode 34, the RV coil electrode36, and the SVC coil electrode 38, respectively.

At the core of the stimulation device 10 is a programmablemicrocontroller 60 which controls the various modes of stimulationtherapy. As is well known in the art, the microcontroller 60 typicallyincludes a microprocessor, or equivalent control circuitry, designedspecifically for controlling the delivery of stimulation therapy and mayfurther include RAM or ROM memory, logic and timing circuitry, statemachine circuitry, and I/O circuitry. Typically, the microcontroller 60includes the ability to process or monitor input signals (data) ascontrolled by a program code stored in a designated block of memory. Thedetails of the design and operation of the microcontroller 60 are notcritical to the present invention. Rather, any suitable microcontroller60 may be used that carries out the functions described herein. The useof microprocessor-based control circuits for performing timing and dataanalysis functions are well known in the art.

As shown in FIG. 2, an atrial pulse generator 70 and a ventricular pulsegenerator 72 generate pacing stimulation pulses for delivery by theright atrial lead 20, the right ventricular lead 30, and/or the coronarysinus lead 24 via an electrode configuration switch 74. It is understoodthat in order to provide stimulation therapy in each of the fourchambers of the heart, the atrial and ventricular pulse generators, 70and 72, may include dedicated, independent pulse generators, multiplexedpulse generators, or shared pulse generators. The pulse generators, 70and 72, are controlled by the microcontroller 60 via appropriate controlsignals, 76 and 78, respectively, to trigger or inhibit the stimulationpulses.

The microcontroller 60 further includes timing control circuitry 79. Thetiming control circuitry 79 is used to control the timing of stimulationpulses (e.g., pacing rate, atrio-ventricular (AV) delay or intervals,atrial interconduction (A-A) delay, or ventricular interconduction (V-V)delay, etc.) as well as to keep track of the timing of refractoryperiods, blanking intervals, noise detection windows, evoked responsewindows, alert intervals, marker channel timing, etc., which is wellknown in the art.

The switch 74 includes a plurality of switches for connecting thedesired electrodes to the appropriate I/O circuits, thereby providingcomplete electrode programmability. Accordingly, the switch 74, inresponse to a control signal 80 from the microcontroller 60, determinesthe polarity of the stimulation pulses (e.g., unipolar, bipolar,combipolar, etc.) by selectively closing the appropriate combination ofswitches (not shown) as is known in the art.

Atrial sensing circuits 82 and ventricular sensing circuits 84 may alsobe selectively coupled to the right atrial lead 20, coronary sinus lead24, and the right ventricular lead 30, through the switch 74 fordetecting the presence of cardiac activity in each of the four chambersof the heart. Accordingly, the atrial (ATR. SENSE) and ventricular (VTR.SENSE) sensing circuits, 82 and 84, may include dedicated senseamplifiers, multiplexed amplifiers, or shared amplifiers. The switch 74determines the “sensing polarity” of the cardiac signal by selectivelyclosing the appropriate switches, as is also known in the art. In thisway, the clinician may program the sensing polarity independent of thestimulation polarity.

Each sensing circuit, 82 and 84, preferably employs one or more lowpower, precision amplifiers with programmable gain and/or automatic gaincontrol, bandpass filtering, and a threshold detection circuit, as knownin the art, to selectively sense the cardiac signal of interest. Theautomatic gain control enables the device 10 to deal effectively withthe difficult problem of sensing the low amplitude signalcharacteristics of atrial or ventricular fibrillation. The outputs ofthe atrial and ventricular sensing circuits, 82 and 84, are connected tothe microcontroller 60 which, in turn, are able to trigger or inhibitthe atrial and ventricular pulse generators, 70 and 72, respectively, ina demand fashion in response to the absence or presence of cardiacactivity in the appropriate chambers of the heart.

For arrhythmia detection, the device 10 utilizes the atrial andventricular sensing circuits, 82 and 84, to sense cardiac signals todetermine whether a rhythm is physiologic or pathologic. As used herein“sensing” is reserved for the noting of an electrical signal, and“detection” is the processing of these sensed signals and noting thepresence of an arrhythmia. The timing intervals between sensed events(e.g., P-waves, R-waves, and depolarization signals associated withfibrillation which are sometimes referred to as “F-waves” or“Fib-waves”) are then classified by the microcontroller 60 by comparingthem to a predefined rate zone limit (i.e., bradycardia, normal, lowrate VT, high rate VT, and fibrillation rate zones) and various othercharacteristics (e.g., sudden onset, stability, physiologic sensors, andmorphology, etc.) in order to determine the type of remedial therapythat is needed (e.g., bradycardia pacing, anti-tachycardia pacing,cardioversion shocks or defibrillation shocks, collectively referred toas “tiered therapy”).

Cardiac signals are also applied to the inputs of an analog-to-digital(A/D) data acquisition system 90. The data acquisition system 90 isconfigured to acquire intracardiac electrogram signals, convert the rawanalog data into a digital signal, and store the digital signals forlater processing and/or telemetric transmission to an external device102. The data acquisition system 90 is coupled to the right atrial lead20, the coronary sinus lead 24, and the right ventricular lead 30through the switch 74 to sample cardiac signals across any pair ofdesired electrodes.

The microcontroller 60 is further coupled to a memory 94 by a suitabledata/address bus 96, wherein the programmable operating parameters usedby the microcontroller 60 are stored and modified, as required, in orderto customize the operation of the stimulation device 10 to suit theneeds of a particular patient. Such operating parameters define, forexample, pacing pulse amplitude, pulse duration, electrode polarity,rate, sensitivity, automatic features, arrhythmia detection criteria,and the amplitude, waveshape and vector of each shocking pulse to bedelivered to the patient's heart 12 within each respective tier oftherapy.

Advantageously, the operating parameters of the implantable device 10may be non-invasively programmed into the memory 94 through a telemetrycircuit 100 in telemetric communication with the external device 102,such as a programmer, transtelephonic transceiver, or a diagnosticsystem analyzer. The telemetry circuit 100 is activated by themicrocontroller by a control signal 106. The telemetry circuit 100advantageously allows intracardiac electrograms and status informationrelating to the operation of the device 10 (as contained in themicrocontroller 60 or memory 94) to be sent to the external device 102through an established communication link 104.

In the preferred embodiment, the stimulation device 10 further includesa physiologic sensor 108, commonly referred to as a “rate-responsive”sensor because it is typically used to adjust pacing stimulation rateaccording to the exercise state of the patient. However, thephysiological sensor 108 may further be used to detect changes incardiac output, changes in the physiological condition of the heart, ordiurnal changes in activity (e.g., detecting sleep and wake states).Accordingly, the microcontroller 60 responds by adjusting the variouspacing parameters (such as rate, AV Delay, V-V Delay, etc.) at which theatrial and ventricular pulse generators, 70 and 72, generate stimulationpulses.

The stimulation device additionally includes a battery 110 whichprovides operating power to all of the circuits shown in FIG. 2. For thestimulation device 10, which employs shocking therapy, the battery 110must be capable of operating at low current drains for long periods oftime, and then be capable of providing high-current pulses (forcapacitor charging) when the patient requires a shock pulse. The battery110 must also have a predictable discharge characteristic so thatelective replacement time can be detected. Accordingly, the device 10preferably employs lithium/silver vanadium oxide batteries, as is truefor most (if not all) current devices.

As further shown in FIG. 2, the device 10 is shown as having animpedance measuring circuit 112 which is enabled by the microcontroller60 via a control signal 114. The impedance measuring circuit 112 is notcritical to the present invention and is shown for only completeness.

In the case where the stimulation device 10 is intended to operate as animplantable cardioverter/defibrillator (ICD) device, it must detect theoccurrence of an arrhythmia, and automatically apply an appropriateelectrical shock therapy to the heart aimed at terminating the detectedarrhythmia. To this end, the microcontroller 60 further controls ashocking circuit 116 by way of a control signal 118. The shockingcircuit 116 generates shocking pulses of low (up to 0.5 joules),moderate (0.5-10 joules), or high energy (11 to 40 joules), ascontrolled by the microcontroller 60. Such shocking pulses are appliedto the patient's heart 12 through at least two shocking electrodes, andas shown in this embodiment, selected from the left atrial coilelectrode 28, the RV coil electrode 36, and/or the SVC coil electrode38. As noted above, the housing 40 may act as an active electrode incombination with the RV electrode 36, or as part of a split electricalvector using the SVC coil electrode 38 or the left atrial coil electrode28 (i.e., using the RV electrode as a common electrode).

Cardioversion shocks are generally considered to be of low to moderateenergy level, and/or synchronized with an R-wave and/or pertaining tothe treatment of tachycardia. Defibrillation shocks are generally ofmoderate to high energy level (i.e., corresponding to thresholds in therange of 5-40 joules), delivered asynchronously (since R-waves may betoo disorganized), and pertaining exclusively to the treatment offibrillation. Accordingly, the microcontroller 60 is capable ofcontrolling the synchronous or asynchronous delivery of the shockingpulses.

New that the device 10 has been generally described, this descriptionwill now continue by describing those elements of the device 10 whichare more particularly employed in this embodiment of the presentinvention. To that end, it may be noted that the device 10 furtherincludes an auto intrinsic conduction search (AICS) circuit 61, anatrial rate detector 62, a PAC detector 63, a PAC counter 64, a resetcircuit 65, and an ALU circuit 66. As shown, each of these circuits isimplemented by the microcontroller 60 but, as may be appreciated bythose skilled in the art, may alternatively be implemented with discretecircuitry.

The AICS circuit 61 may function as previously described to encourageintrinsic ventricular activity. Hence, it may cause the timing control79 to time the extended AV interval when active to encourage intrinsicventricular activity and be reset to cause the timing control to timethe shorter base AV interval.

The atrial rate detector 62 preferably times atrial based intervals. Theatrial based intervals may be the time between R waves and P waves/Awaves. Alternatively, the atrial based intervals may be the time betweenan atrial activation (A wave or P wave) of one cardiac cycle and anatrial activation (A wave or P wave) of the next cardiac cycle. Theatrial based intervals may be the time between consecutive R waves (orV-R intervals) as long as each ventricular event is preceded by anatrial event.

The PAC detector may use the atrial based intervals timed by the atrialrate detector 62 to detect PACs. This may be accomplished by subtractingthe previously R to P/A or P/A to P/A interval from a current R to P orP/A to P interval to determine a difference (A). The difference may thenbe compared to a predetermined standard, such as, for example, 50 ms to150 ms cycle to cycle variation. If the difference in absolute intervals(ms) is greater than the predetermined standard, detection of a PAC isdeclared. A PAC may also be determined using percentages if R to P orP/A to P interval is shorter than the base interval by a specifiedpercentage.

If the difference is not less than the predetermined standard, the AICSwill not receive PAC protection treatment. In this setting, if theatrial rate is above the upper atrial rate limit or if there is anextended AV interval time-out and a ventricular pacing be issued, theAICS AV interval will be reset to the base interval. This will thenfollow the standard algorithm behavior for AICS.

The PAC counter 64, as will be seen subsequently keeps track of thenumber of consecutive PACs. This is performed because the PAC AICSprotection may be desired for each one of a predetermined number ofconsecutive PACs. When the predetermined number of consecutive PACsoccur, the AICS AV interval will be reset. Hence, if one PAC is to betolerated without an AICS AV interval reset, the predetermined numberwould be two. If X consecutive PACs are to be tolerated, then thepredetermined number would be X+1.

The reset circuit 65 resets the AICS AV interval. It may take input fromthe PAC detector 63, the atrial rate detector 62, the timing control 79,and the PA counter. If the PAC is detected, the reset circuit 65 willnot reset the AICS AV interval unless the predetermined number ofconsecutive PACs have been reached. If the predetermined number of PACshas been reached, reset circuit will reset the AV interval to the baseinterval.

If the reset circuit 65 receives input from the atrial rate detectorthat the atrial rate is above the upper atrial rate and there is no PAC,the reset circuit 65 will reset the AICS AV interval to the baseinterval. The AV interval will also be reset whenever there is atime-out of the extended AV interval and a ventricular pacing pulse isissued.

The ALU 66 is provided to process required arithmetic functions. Forexample, the ALU 66 may be called upon to function as a subtractor forcalculating the difference (Δ). It may also be used for division forcalculating cardiac rates based upon cardiac intervals.

In FIG. 3, a flow chart is shown describing an overview of the operationand novel features implemented in one embodiment of the device 10. Inthis flow chart, the various algorithmic steps are summarized inindividual “blocks”. Such blocks describe specific actions or decisionsthat must be made or carried out as the algorithm proceeds. Where amicrocontroller (or equivalent) is employed, the flow charts presentedherein provide the basis for a “control program” that may be used bysuch a microcontroller (or equivalent) to effectuate the desired controlof the stimulation device. Those skilled in the art may readily writesuch a control program based on the flow charts and other descriptionspresented herein.

The process of FIG. 3 is more particularly directed to providing theAICS 61 with PAC protection and resetting the AICS extended AV intervalto the base AV interval which then begins again a period in whichintrinsic conduction is analyzed before the extended AV interval is onceagain reinstated. It is to be understood that, in this embodiment,whenever there is a time-out of the extended AV interval that the AICSis reset reinstating the base AV interval.

The process of FIG. 3 initiates with decision block 120. Here, it isdetermined if the auto intrinsic conduction search circuit 61 is active(set). If it is not active, the process returns. However, if the AICS isactive, the process then advances to decision block 122. In decisionblock 122, it is determined if the premature atrial contractionprotection for the AICS process is active. If it is not, the processreturns. However, if the PAC protection is active, the process advancesto decision block 124.

In decision block 124, it is determined if there is an atrial rateincrease. Decision block 124 may be implemented by comparing theatrial-based interval of the current cardiac cycle with the atrial-basedinterval of the immediately preceding cardiac cycle. If the atrial-basedinterval of the current cardiac cycle is shorter than the atrial-basedinterval of the previous cardiac cycle, an atrial rate increase will bedeclared and the process advances to decision block 126. If an atrialrate increase is not declared, the process then returns to look for anatrial rate increase during the next cardiac cycle.

In decision block 126, it is determined if the interval is shorter thana particular interval of X milliseconds. The interval of X millisecondsis chosen so as to represent the upper atrial rate minimum interval. Aspreviously described, the upper atrial rate may be 90 beats per minute(bpm). This would correspond to a minimum interval of 666 milliseconds.If the upper atrial rate limit is 90 bpm, it is determined in decisionblock 126 if the last atrial interval is less than 666 milliseconds. Ifit is not, the process returns to decision block 124. However, if it is,the process advances to decision block 128 to determine if the atrialrate above the upper atrial limit for the current cardiac cycle resultedfrom a premature atrial contraction. The presence of a PAC may bedetermined as previously described by subtracting an atrial-basedinterval of the current cycle from the atrial-based interval of theimmediately preceding cardiac cycle to determine a difference and thencomparing that difference to a predetermined standard between 50 to 150milliseconds, for example. If the difference is greater than thepredetermined standard, the detection of a PAC will be declared.However, if the difference is less than a predetermined standard, thedetection of a PAC will not be declared.

Those skilled in the art will appreciate that there are a number ofdifferent ways in which a PAC may be detected. For example, a PAC may bedetected by monitoring A to A or V to V intervals and if a nativecomplex occurs that is more premature based upon a percentage of thepreceding cycle length, detection of a PAC may be declared. Othermethodologies for detecting PACs are also available. Hence, it is to beunderstood, that the particular method of detecting PACs describedherein is exemplary only.

If a PAC is detected in accordance with decision block 128, the processadvances to activity block 130 wherein any attempt to reset the AICS AVinterval to the base interval is overridden to maintain the extended AVinterval. Hence, the reset circuit 65 does not cause the AICS circuit 61to in turn cause the timing control 79 to start timing the base AVinterval. Next, the process advances to activity block 132 where the PACcounter 64 is updated. The PAC counter 64 will now have the most recentconsecutive number of detected PACs since the last AICS AV intervalreset. After activity block 132, the process advances to decision block134, wherein it is determined if the count in the PAC counter 64 isequal to the predetermined number. If it is, indicating that thepredetermined number of PACs have occurred while the AICS is active, theprocess advances to activity block 136 for resetting the AV interval ofthe AICS to the base interval for the next cardiac cycle and to initiatethe period in which the AICS evaluates the intrinsic conduction of thepatient. As previously described, if one PAC is to be tolerated, thenthe predetermined number to which the counter is compared in decisionblock 134 would be 2. If the number of consecutive PACs to be toleratedis 2 PACs, the predetermined number to which the PAC counter count iscompared in decision block 134 is 3, and so on. If in decision block 134it is determined that the PAC counter count is not equal to apredetermined number, a process returns to decision block 124 to assessthe next cardiac cycle for an atrial rate increase. Following reset ofthe AV interval in activity block 136, the process returns.

Returning now to decision block 128, if in decision block 128 it isdetermined that a PAC has not been detected, the process advances toactivity block 138 wherein the PAC counter 64 is reset. Thenon-detection of a PAC in decision block 128 breaks the consecutivechain of PAC detections.

At this point in the process, a PAC has not been detected but an atrialrate greater than the upper atrial rate has been detected. In thisevent, the process advances to activity block 142 wherein the AVinterval of the AICS is reset to the base interval to initiate theperiod of intrinsic conduction analysis. Following activity block 142,the process returns.

Hence, as may be seen from the foregoing, intrinsic conduction of apatient is encouraged by the AICS process. The AICS process hasprotection from premature atrial contractions. Hence, a premature atrialcontraction while the AICS is causing the timing control 79 to time theextended AV interval will not cause the AV interval to be reset to thebase AV interval. The process is arranged to tolerate a number ofconsecutive PACs without resetting the AV interval to the base interval.In addition, whenever there has been an AV time-out of the extended AVinterval and a ventricular pacing pulse issued, the AICS is reset toreinstate the base AV interval. In another implementation, the devicemay recognize a PAC and the effective PAC rate may exceed the ratecutoff for the AICS algorithm. For the PAC complex only, the system mayreturn to the programmed base AV delay but, because this is in responseto a PAC, the AICS extension is not suspended. On the next cycle, inwhich a normal sinus complex occurs at a rate below the rate cutoff, theAICS extension will still be in effect allowing for appropriateinhibition of the ventricular channel. Hence, activity block 130 of FIG.3 may be modified to cause the timer 79 to time the base AV interval forthe current cardiac cycle (the PAC cycle) while maintaining the setcondition of the AICS 61.

While the invention has been described by means of specific embodimentsand applications thereof, it is understood that numerous modificationsand variations could be made thereto by those skilled in the art withoutdeparting from the spirit and scope of the invention. It is therefore tobe understood that within the scope of the claims, the invention may bepracticed otherwise than as specifically described herein.

1. An implantable cardiac stimulation device comprising: one or moreelectrodes adapted for coupling with cardiac tissue; a pulse generatoradapted to output pacing pulses to the electrodes; a converter adaptedto sense cardiac polarizations through the electrodes; and a controllercoupled to the pulse generator and the converter and having code storedtherein that defines a base inhibit internal and an extended inhibitinterval, the controller programmed to: periodically control the pulsegenerator to deliver pacing pulses upon expiration of the extendedinhibit interval while processing the cardiac polarizations sensed bythe converter to determine if the cardiac rate has increased by athreshold amount and if the cardiac rate has increased by a thresholdamount, to detect for premature contractions; control the pulsegenerator to deliver pacing pulses upon expiration of the base inhibitinterval if the cardiac rate has increased by a threshold amount and nopremature contractions are detected; and control the pulse generator todeliver pacing pulses upon expiration of the extended inhibit intervalif the cardiac rate has increased by a threshold amount and one or morepremature contractions are detected.
 2. The device of claim 1 whereinthe cardiac polarizations sensed by the converter comprise atrialpolarizations and the cardiac rate is based on consecutive atrialpolarizations.
 3. The device of claim 1 wherein the cardiacpolarizations sensed by the converter comprise atrial polarizations andventricular polarizations and the cardiac rate is based on intervalsfrom a ventricular polarization to a succeeding atrial polarization. 4.The device of claim 1 wherein the pulse generator is a ventricular pulsegenerator and the inhibit interval is an atrio-ventricular (AV)interval.
 5. The device of claim 1 wherein if the cardiac rate hasincreased by a threshold amount and one or more premature contractionsare detected, the controller is further programmed to maintain a countof detected premature contractions and control the pulse generator todeliver pacing pulses upon expiration of the base inhibit interval afterthe premature contractions count exceeds a predetermined number.
 6. Thedevice of claim 1 wherein the premature contractions comprise prematureatrial contractions (PACs).
 7. The device of claim 6 wherein thecontroller is programmed to detect PACs by: subtracting a current atrialbased interval from an immediately preceding atrial based interval toprovide a difference; and comparing the difference to a predeterminedstandard to detect a premature atrial contraction.